MEDICARE: PUSH FOR RECOVERY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency
2	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1336753466
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PUSH FOR RECOVERY, LLC

Provider Business Mailing Address
First Line	:	5944 EPERNAY WAY
Second Line	:
City	:	GALLOWAY
State	:	OH
Zip	:	43119-8588
Country	:	US
Telephone Number	:	614-507-0713
Fax Number	:

Provider Business Practice Location Address
First Line	:	3880 CLIME ROAD
Second Line	:	BUILDING 2/SUITE A
City	:	COLUMBUS
State	:	OH
Zip	:	43228-3532
Country	:	US
Telephone Number	:	614-507-0713
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RICHARD FANNIN
Credential	:
Telephone Number	:	614-507-0713

Provider Enumeration Date	:	09/05/2020
Last Update Date	:	09/05/2020

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Directions to “PUSH FOR RECOVERY, LLC ” Practice Location

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